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Streptokokkenmediastinitis nach Thyreoidektomie

Eine Literaturübersicht

Streptococcal mediastinitis after thyroidectomy

A literature review

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Zusammenfassung

Einleitung

Wundinfektionen nach Schilddrüsenoperationen sind überwiegend oberflächlich und gut zu therapieren. Eine Streptokokkenmediastinitis nach Thyreoidektomie stellt eine sehr seltene, jedoch lebensbedrohliche Komplikation dar.

Fallbericht

Zwei Tage nach Thyreoidektomie wegen einer Basedow-Struma trat bei einer 57-jährigen Patientin septisches Fieber, hohe Entzündungsparameter und eine inflammatorische Hautrötung im Bereich der Operationswunde auf. Ursache war eine tiefe 3-Kompartment-Infektion durch Streptokokken der Gruppe A (GAS) unter Einbeziehung des hinteren Mediastinums. Sieben Wundrevisionen in Vollnarkose, die adaptierte Antibiose und eine zervikale Unterdrucktherapie konnten die lebensbedrohliche Infektion nach 6-wöchiger Behandlungsdauer beherrschen. In der Literatur sind 21 Fälle beschrieben, davon 11 mit letalem Ausgang.

Schlussfolgerung

Hohes Fieber, Entzündungsparameter und lokale Inflammation in der frühpostoperativen Phase nach Thyreoidektomie sind Hinweise für eine GAS-Infektion. Es besteht die Gefahr einer nekrotisierenden und deszendierenden Mediastinitis mit vitaler Bedrohung. Rasche Diagnostik, CT, Etappenlavagen mit Wundabstrich, intravenöse antibiotische Therapie mit Penicillin G und Clindamycin sind dringlich geboten. Bei Therapieresistenz ist an eine zervikale Unterdrucktherapie zu denken.

Abstract

Introduction

Surgical site infections after thyroid surgery are mostly superficial and can be well treated. Streptococcal mediastinitis in contrast is a rare but life-threatening complication.

Case report

A 57-year-old female patient experienced septic fever, increase of inflammation parameters and erythema 2 days after thyroid surgery for Graves’ disease. This process was triggered by a three-compartment infection by group A Streptococcus (GAS) with involvement of the mediastinum. Therapy over 6 weeks including seven wound revisions with the patient under general anesthesia, pathogen-adapted antibiotic treatment and cervical negative pressure treatment managed to control the infection. A total of 21 cases have been published on this phenomenon, 11 of which had a fatal outcome.

Conclusion

High fever and surgical site erythema in the early postoperative period after thyroid surgery can be signs of a GAS infection, which might lead to necrotizing, descending, life-threatening mediastinitis. Early diagnosis with support of computed tomography (CT) scans, immediate therapy including wound opening, lavage, intravenous antibiotic treatment with penicillin and clindamycin are vital. If treatment resistance occurs, cervical negative pressure treatment should be considered.

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Abbreviations

ASA-Score:

American Society of Anesthesiologists

CDC:

Centers for Disease Control and Prevention

CFR:

case fatality ratio

CNP:

controlled negative pressure

CT:

Computertomographie

GAS:

Gruppe-A-Streptokokken

NNIS-Scores:

National Nosocomial Infections Surveillance System

STSS:

streptococcal toxic shock syndromes

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Einhaltung ethischer Richtlinien

Interessenkonflikt. C. Bures, V. Zielinski, T. Klatte, N. Swietek, F. Kober, E. Tatzgern, R. Bobak-Wieser, E. Gschwandtner, M. Gilhofer, A. Wechsler-Fördös und M. Hermann geben an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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Bures, C., Zielinski, V., Klatte, T. et al. Streptokokkenmediastinitis nach Thyreoidektomie. Chirurg 86, 1145–1150 (2015). https://doi.org/10.1007/s00104-014-2972-y

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